Sulfonylurea Rx Too Common in Vets with CVD

by Ed Susman Contributing Writer, MedPage Today

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Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

May patients with diabetes and cardiovascular disease are still prescribed sulfonylureas in Veterans Affairs hospitals, despite warnings against the practice.

Note that the study found that the use of sulfonylureas among veterans with either a history of cardiovascular disease or multiple risk factors for cardiovascular disease (CVD) was similar to those at low risk for CVD.

BARCELONA -- Many patients with diabetes and cardiovascular disease have been prescribed sulfonylureas in Veterans Affairs hospitals -- despite warnings against the practice, researchers reported here.

After reviewing records of 60,275 patients with at least 2 diabetes-related visits, Lizheng Shi, PhD, associate professor of public health at Tulane University in New Orleans, found that 24.92% of patients with diabetes and established heart disease were prescribed sulfonylureas -- drugs that are supposed to be given with caution to this population.

In fact, based on his poster presentation at the American Diabetes Association and EASD, the VA added language that contained improvements over the previous 2009 treatment suggestions. “Specifically they recommend that sulfonylureas be avoided in patients with cardiovascular disease risk based on current literature, which [indicates] increased cardiovascular mortality among sulfonylurea users,” he said.

He also noted that "there is still a serious concern regarding the use of sulfonylureas among high-risk populations, given the elevated risk of hypoglycemia and cardiovascular disease associated with these drugs in Type 2 diabetes patients alone or in combination with other therapy."

For the study, Shi and colleagues combed the Veterans Affairs electronic medical records from January 2004 through January 2011, identifying Type 2 diabetes patients using hospital codes. Individuals at least 18 years of age were included; Type 1 diabetes patients were excluded.

The patients were then stratified by cardiovascular risk: They identified 16,913 patients with established cardiovascular disease; 30,348 patients with multiple risk factors for cardiovascular disease and 13,014 patients with no cardiovascular risk factors. As expected, those with established heart disease were older -- mean age 67.82 years; compared with those having multiple risk factors, 66.27 years; and no risk factors 51.52 years (P<0.01).

Shi also looked at metformin use in the 3 groups and found that the drug was prescribed to 44.21% of patients with established coronary disease; to 52.08% of patients with multiple risk factors and to 62.59% of those with no cardiovascular disease and no risk factors for coronary disease.

"We see that despite the cautions associated with sulfonylureas, that doctors are still using it in their patients," he said. "I think one reason for its continued use is that it is a very inexpensive treatment."

"Although I have no data on this myself, I think that from clinical practice this is pretty accurate as to what happens elsewhere in the world. There is concern about hypoglycemia with sulfonylureas. I think there may be a lot of treatment inertia as well," said Patrick Holmes, MBBS, a general practice physician with the U.K. National Health Service, in Darlington, England.

"It is concerning to me that there does not seem to be any differential between high-risk patients and low risk patients in prescribing sulfonylureas," he told MedPage Today while reviewing the poster presentation. He was not a participant in the study.

"I think this study reflects that most patients are being treated by primary care physicians or cardiologists and they may not fully understand the concerns," he commented. "Obviously, we would like to see some prospective outcomes because there still is controversy about the safety of sulfonylureas. This is important, but we don't yet have all the pieces of the jigsaw puzzle."

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